Along with four technical reports, the NESC produced a four-page newsletter summarizing the technical activities and some lessons learned. The biggest lesson, Roe said, is to curb the practice of "PowerPoint engineering." The Columbia report chided NASA engineers for their reliance on bulleted presentations. In the four studies, the inspectors came to agree that PowerPoint slides are not a good tool for providing substantive documentation of results. "We think it's important to go back to the basics," Roe said. "We're making it a point with the agency that engineering organizations need to go back to writing engineering reports."
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The reports from the NASA Engineering and Safety Center, based at Langley Research Center in Hampton, Va., are laced with reminders about managing risk, listening to dissenters, certifying flight hardware and limiting workloads. "We will be communicating the lessons and assigning actions across the agency," NESC director Ralph Roe told reporters Wednesday.

Roe briefed reporters after sharing the results of four studies with senior NASA leaders in Washington. The approach, actively sharing lessons learned, is borrowed from the U.S. Navy's Board of Inspection and Survey.

The initial assessments covered a problem with the space shuttle's rudder and speed brake system, the Mars rover landings earlier this year, the record-breaking flight of an experimental NASA aircraft in March, and a joint science mission with the French space agency.

On the French mission, called CALIPSO, the safety center looked at concerns about possible leaks of highly reactive spacecraft fuel. It held the flight of NASA's X-43A hypersonic craft until one team member's dissenting opinion about the vehicle's aerodynamic characteristics was addressed properly. On the Mars rovers, the safety center reviewed spacecraft instrumentation and plans for around-the-clock mission staffing.

Along with four technical reports, the NESC produced a four-page newsletter summarizing the technical activities and some lessons learned. The biggest lesson, Roe said, is to curb the practice of "PowerPoint engineering." The Columbia report chided NASA engineers for their reliance on bulleted presentations. In the four studies, the inspectors came to agree that PowerPoint slides are not a good tool for providing substantive documentation of results. "We think it's important to go back to the basics," Roe said. "We're making it a point with the agency that engineering organizations need to go back to writing engineering reports."

The NESC was created to serve as a source of expertise for evaluating the merits of technical concerns identified by agency employees. Its funding is not linked to any single NASA program or project, making it free from schedule or cost bias.

The center employs about 60 people full-time at NASA's Washington headquarters and 10 field installations in Alabama, California, Florida, Maryland, Mississippi, Ohio, Texas and Virginia. Up to 200 others from government agencies, industry and academia provide part-time support for individual cases.

Roe said his organization is one of the best examples of NASA's changing safety culture. Drawing experts from across the space agency breaks down the "stove-piping" compartmentalization tendencies criticized by the Columbia Accident Investigation Board, and the center's work is independent.

The center tries not to duplicate efforts by NASA program teams. But when parallel analyses are done and the data differ, Roe's NESC rules. "We have the authority to constrain a milestone or stop a flight or stop using a piece of hardware," he said.

In six months, the NASA Engineering and Safety Center has handled 49 requests. About one-fourth were generated by the space agency itself. The rest came independently from engineering and safety experts, senior managers, and at least two anonymous tipsters.

Although the center's $45 million budget has been "adequate for ramping up," Roe told reporters it may not be sufficient for NESC to handle future requests. They are being submitted at a rate of 200 per year, and "I think we will need a larger budget for this," he said.

The NESC is not to be confused with the independent technical engineering authority that Columbia accident investigators instructed NASA to establish. The agency's chiefs of engineering and safety still are working out the details for separate authorities at each NASA location. Roe's office will collaborate with them.

In the past year I've given my one-day course on presenting data and information to
about 1,000 NASA employees at their various locations around the country. I've modified
my public course to deal with some of the special concerns at NASA, including ideas on
how decision-makers should monitor and assess technical reports and, of course, what
good technical reports should do. The quality of technical reporting and the quality of
monitoring technical reports were major issues in the 2 shuttle accidents.

It is a bit daunting to present my analyses of the Challenger and the Columbia accidents to
insiders but the best I can do for NASA is to say what I have to say. I often repeat Richard
Feynman's famous conclusion to his appendix to the Challenger commission report: "For a
successful technology, reality must take precedence over public relations, for Nature
cannot be fooled." That conclusion remains relevant today.

In addition, I'm currently helping with the risk assessments for the shuttle on its return to
flight.

-- Edward Tufte

It seems that NASA (and the NTSB) are not completely unfamiliar with design considerations when it comes to safety. Several
studies were funded on designing checklists since it was found that improper design contributed to accidents. Some of the
reports available:

They were published in the early 1990s, so perhaps people forgot about them? (On a side note, #1 and #2 seem to be the
product of your typical word processor, but #3 feels quite well laid out IMHO--it even has a mini colophon.)